orchestrating global polio eradication...the global polio eradication initiative (gpei) is one of...

A Unique AllianceThe Global Polio Eradication Initiative (GPEI) is

one of the largest public health programs ever.

Over the last 30 years, the program has en-

gaged millions of health workers and volun-

teers, delivered polio vaccines to the most

remote corners of the planet, and managed

billions of dollars. The organizational and

logistical challenges have been enormous as

the five core partners worked with nation-

al governments and other collaborators to

extinguish the polio virus in every part of

the world.

“GPEI as it is now… really is a unique governance structure which no other health

program has been able to follow... I’m sure that to the extent that eradication has been

successful, it’s due not least to this governance structure.”

– Bjorn Melgaard, Independent Global Health Policy Consultant

This sixth installment in our series on U.S. support for global polio eradication explores the evolution of the Global Polio Eradication Initiative, discussing how its multi-layered governance model, while unwieldy at times, has proven the value of partnerships through its success.

Orchestrating Global Polio EradicationBy Nellie Bristol & Michaela Simoneau | SEPTEMBER 2019

ORCHESTRATING GLOBAL POLIO ERADICATION | 1

Source: World Health Organization

2 | CENTER FOR STRATEGIC AND INTERNATIONAL STUDIES

The World Health Organization (WHO),

UNICEF, Rotary International, the U.S.

Centers for Disease Control and Preven-

tion (CDC), and the Bill & Melinda Gates

Foundation lead the initiative through a

unique governance structure that evolved

organically based on the needs of the

program and the desires of partners and

major donors. The resulting multi-layered,

somewhat bureaucratic alliance has been

highly effective despite its flaws, reducing

the number of wild polio cases worldwide

by more than 99 percent.

Humble BeginningsIn 1988, a World Health Assembly reso-

lution committed all countries to global

polio eradication. The initiative was

launched as a small program within

the WHO’s immunization division, the

Expanded Programme on Immunization

(EPI). It was led officially by WHO but

supported through an informal alliance

with the original partners, UNICEF, CDC,

and Rotary. The number of polio cases

fell rapidly at first, as countries with solid

immunization systems added the vaccine to their schedules or used their existing networks to

conduct national polio immunization campaigns.

“One of the things that makes [the GPEI] unique is that it wasn’t organized initially

around a governance structure and it continues to be unconventional. At the start, it

was a freeform alliance of different organizations each raising money.”

– Ellyn Ogden, Worldwide Polio Eradication Coordinator, U.S. Agency for International Development

The initiative encountered its first obstacles when it began to focus on regions with weaker

health infrastructure that had fewer health workers and financial resources. Since these coun-

tries lacked strong existing immunization networks, the task of reaching every child required

A child in Vanuatu is vaccinated against polio. Source: UNICEF via Getty Images

World Health Organization meeting in 1988 that resulted in the founding of the GPEI. Source: World Health Organization

http://polioeradication.org/wp-content/uploads/2016/07/19880513_resolution-2.pdf

http://polioeradication.org/wp-content/uploads/2016/07/19880513_resolution-2.pdf

the program to organize and fund

vaccination campaigns itself, including

resource-intensive house-to-house vac-

cine delivery.

As the eradication program’s responsi-

bilities grew, so did its need for financ-

ing. When the program began, planners

predicted the task of polio eradication

would cost $155 million and be com-

pleted by 2000.1 Instead, its budget has

hovered around $1 billion a year since

2011, and total costs are now $17 billion

over its lifetime.2

By 1998, the program was still struggling to meet its goals. WHO increased its advocacy and

fundraising efforts and hired a director devoted specifically to polio eradication. With new

management and focus, the program picked up steam. In order to gain visibility and develop its

own fundraising brand, the GPEI began to operate separately from the EPI under the name of the

Global Polio Eradication Initiative.

Finding a New PathIn the mid- to late-2000s, the initiative

stalled again. The GPEI had been missing

targets and struggling to extinguish the

virus in the last few endemic countries:

India, Afghanistan, Pakistan, and Nige-

ria.3 GPEI management was criticized for

its lack of transparency and being unduly

positive about the program’s progress.

Some criticized the initiative for its

overly centralized, inflexible operational

style that allowed it to “stick doggedly to

a particular course of action, regardless of whether it was working or not.”4

These issues, combined with a failure to achieve eradication, led to dissatisfaction among

some partners, which now included the Gates Foundation. The partners commissioned several

management reviews starting in 2010 and developed new oversight bodies. These included the

Polio Oversight Board (POB), a panel of the top executives from each of the core partners, and

In Bangladesh, a doctor and her assistant prepare to take polio vaccines via rickshaw to families in local slums. Source: Gavi

Source: Jean-Marc Giboux/Getty Images



the Polio Partners’ Group, which pulled together a range of donors and other stakeholders. An

accountability mechanism also was added—the Independent Monitoring Board of the Global

Polio Eradication Initiative (IMB).

The IMB began issuing assessments that often were critical of GPEI management. For exam-

ple, in a 2011 report it asked, “How can it be that individuals known to be tired and inef-

fective are allowed to remain in key leadership positions?”5 WHO ultimately reconfigured

its polio team, the other four core partners took on stronger decision-making roles, and

governance became more horizontal and consensus-based.

“If you look back at the structures we had to accommodate, all the different partners

and agencies that wanted to have a stronger voice, it made [the GPEI] evolve into a

fairly unwieldy bureaucracy because of the expectation that each agency would be rep-

resented on every level of technical as well as decision-making bodies.”

– Brent Burkholder, Independent Global Public Health Consultant

The structure now operates without a central authority, and all the partners spend an enor-

mous amount of time discussing issues and deciding on a course of action as a group. Despite

the loss in efficiency, the GPEI has continued to improve eradication infrastructure while

ensuring continued partner commitment.

Geopolitical Hurdles In the late-2010s, the program began

facing fatigue on the part of some coun-

try-level administrators and resistance

from some parents of children repeatedly

approached by polio vaccinators.6 Howev-

er, a more pressing concern has been the

national and geopolitical obstacles in the

remaining endemic countries that limit

its access to unvaccinated children.

Global Polio Caseload 2000-2019

Polio

Cas

es

Afghanistan

India

Nigeria

Pakistan

Other Countries

2000 2005 2010 2015

0

500

750

250

1000

1250

1500

1750

2000

CSIS Global Health Policy Center | Source: World Health Organization

Source: Asif Hassan/AFP/Getty Images

In April, the Afghanistan Taliban banned WHO from operating in its territory.7 The Pakistan pro-

gram has suffered deadly violence against polio vaccinators fed by unfounded rumors about the

vaccine and by the program’s (false) association with the U.S. hunt for Osama bin Laden.8 Inse-

curity and insurgent activity by Boko Haram in northern Nigeria has blocked both vaccination

campaigns and disease surveillance efforts.

“At this point, a fundamental issue

preventing eradication is lack of

access to unvaccinated children.

It’s not that we merely need a

better manager or improved supply

chain to achieve eradication—the

fundamental issue is lack of access

in areas controlled by anti-govern-

ment elements.”

– Amb. John Lange, Senior Fellow,

Global Health Diplomacy, United

Nations Foundation

As the GPEI attempts to respond to new challenges, management entities—largely task teams

and working groups—have proliferated. In a somewhat ironic result, the GPEI governance

structure has grown dramatically, even as its global caseload has shrunk. This reflects the com-

plexity of the polio endgame. The GPEI still labors to reach its ultimate goal, and it is unclear

whether the strategic management expansion has truly helped.

“The reasons that polio has not been eradicated really aren’t related to the organization

structure in Geneva. So no amount of restructuring in Geneva will get us to eradication.

And they know that.”

– Mara Pillinger, PhD Candidate, The George Washington University

In October 2018 an independent team commissioned by the IMB to review progress in the

remaining endemic countries questioned whether “this elaborate structure remains fit for pur-

pose, or whether it may now be a drag on country level efforts.”9 Others note that much of what

is hindering eradication at this point is beyond the control of program management. “The fight

to eradicate polio will be won (or lost) on the ground,” one researcher noted. “Even if GPEI HQ

were to implement the most successful change initiative of all time, the program’s key security,

political, and socio-cultural challenges can only be solved at the country level.”10

Pakistani children look at a health centre torched by a mob following rumours of reactions to polio vaccination in April 2019. Source: Abdul Majeed/AFP/Getty Images



Private-sector Partners By working at both the country and global

levels, private-sector organizations have

driven and sustained what is essentially

a public heath campaign. Rotary, an in-

ternational service organization with 1.2

million business and professional mem-

bers, committed to polio eradication as an

organizational goal in the mid-1980s.

So far, Rotary has donated $1.9 billion to

the effort. In addition, Rotary members

have volunteered for local vaccination campaigns and advocated for the initiative at all levels of

government. Despite being a private-sector organization, Rotary has been a key partner in GPEI

management from the very beginning.

The Gates Foundation first joined the GPEI in the early 2000s as a donor but has since be-

come one of its most active partners. Polio eradication is now one of the Gates Foundation’s

top priorities, and Bill Gates personally urges government officials and donors to maintain

their commitments.

In addition to providing technical, policy, and programmatic support, the foundation is now

the GPEI’s top donor, with contributions totaling $3.6 billion as of the end of 2018. By compari-

son, the U.S. government has contributed $3.3 billion over the past 30 years.11

The Gates Foundation notes that it plays

a unique role in the GPEI because it

has the “ability to contribute by taking

big risks and making nontraditional

investments. Examples include our

investments in vaccine research and our

establishment of emergency operations

centers in Nigeria, Pakistan, and Afghan-

istan.”12 With its enormous resources and

flexibility as a private-sector entity, the

Gates Foundation has been able to iden-

tify and respond immediately to program

gaps that the frequently cash-strapped

WHO, CDC, and UNICEF would have

been hard-pressed to address.

Source: Rizwan Tabassum/AFP/Getty Images

GPEI Contributions by Donor 1985-2018

Bill & Melinda Gates Foundation19.6%Bill & Melinda Gates Foundation19.6%

United States of America18.2%United States of America18.2%

Rotary International10.3%Rotary International10.3%United Kingdom

8.7%United Kingdom8.7%

India7.3%India7.3%

Contributions betweenContributions between$10 - $100 million$10 - $100 million5.2%5.2%

Contributions between$10 - $100 million5.2%

Germany3.6%Germany3.6%

National PhilanthropicTrust and PrivatePhilanthropists3.4%

National PhilanthropicTrust and PrivatePhilanthropists3.4%

Canada3.3%Canada3.3%

Japan3.1%Japan3.1%

World Bank Credits to India2.8%World Bank Credits to India2.8%

World Bank InvestmentPartnership for Polio2.3%

World Bank InvestmentPartnership for Polio2.3%

1.8%Islamic Development Bank Loan to the Government of Pakistan1.8%

European Commission1.6%European Commission1.6%

CSIS Global Health | Source: Polio Global Eradication Initiative

A Broader Focus While Rotary and the Gates Foundation

play a pivotal role in the GPEI, some

speculate that the program’s high visibili-

ty and association with U.S. organizations

may now be hurting the effort. The pro-

gram has been struggling to extinguish

the virus in areas of Pakistan and Af-

ghanistan that have a high concentration

of anti-Western sentiment. While U.S.

support will remain critical to successful

eradication, the current environment

seems to call for yet another governance

and communications shift in order to lower the GPEI’s profile in these challenging geographies.

This realignment will also require integrating polio vaccination more into country immuniza-

tion programs rather than operating through separate vaccination campaigns. In exploring that

option, the POB has added the executive director of Gavi, the Vaccine Alliance, to its member-

ship. Gavi focuses on the provision of a range of vaccines to low-income countries.

“The governance structure of a mostly vertical program such as polio eradication has

all of these difficulties as it comes very close to reaching its goal, but the only way it

can really succeed and sustain the gains is through a horizontal routine immunization

program that will maintain essential polio functions.”

– Amb. John Lange, Senior Fellow, Global Health Diplomacy, United Nations Foundation

This new partnership has required some adjustment but to many is long overdue. The IMB rec-

ommended as early as October 2014 that the GPEI make Gavi part of the partnership as a way

to boost its commitment to broader immunization systems. “Although it appears prominently

in the strategic plan, routine immunisation is treated by the main body of the polio programme

as if it is some side issue – a ‘nice-to-do’ not a ‘need-to-do’,” the IMB noted. “This is short-sight-

ed. It may, in Pakistan, be key to reaching those children whose parents are fed-up of repeated

polio-only campaigns but would willingly accept a package of vaccinations for their children.”13

The Power of Partnership Despite eradication’s many challenges and the GPEI’s potentially cumbersome structure, the

GPEI continues to operate effectively. Its unique use of a consensus-based “club governance

model” allows partner principals to operate as a unit separate from their parent organizations.

Source: UNF/McNab


https://www.csis.org/analysis/polio-eradication-needs-gavi-collaboration


“The GPEI is an impressive management

entity, with a cohesive amalgam of

partners that has embraced a common

goal and ceded policy-making powers to

this body in pursuit of that goal,” noted

the Transition Independent Monitoring

Board, a panel convened to oversee the

integration of polio infrastructure into

country health systems. Through this

alliance, the initiative “has created a

leadership and accountability function

that is unprecedented in global health,”

the board added.14

The longstanding engagement of all

partners and their leaderships’ direct buy-in through the POB has given the polio program

unmatched commitment both to the goal of eradication and to the partnership itself. “The core

partners consider themselves as being in a long term, close-knit relationship. They are in this

together until the end; they will succeed or fail as a unit; and they are committed to collaborat-

ing to get the job done.”15

“There is a commitment in the

organization that goes beyond

anything else that I’ve seen in any

other public global health program.”

– Bjorn Melgaard, Independent Global

Health Policy Consultant

Over time, the GPEI has proven the value

of strong partnerships where each orga-

nization has an equal say and illustrates

the vital role the private sector can play

in public health. It also reflects how

governance changes, painful as they may be, are part of a necessary evolution to respond to

realities on the ground.

The last chapter for polio eradication remains to be written, and other reforms may be neces-

sary before the program can succeed. However, the GPEI’s commitment to inclusive manage-

ment will continue to offer important lessons for the successful implementation of other global

health programs.

Source: United States Mission Geneva

Indian schoolgirls hold signs celebrating their country being polio-free in 2012. Source: Noah Seelam/AFP/Getty Images

About the AuthorsNELLIE BRISTOL is a senior fellow with the CSIS Global Health Policy Center. She leads the Center’s

work on efforts to repurpose polio eradication assets for long-term disease control and toward other

global health priorities. In addition to an active working group convened to discuss eradication and

transition as it relates to U.S. global health policy, she writes extensively on the issue and consults

with other organizations focused on transition planning. She also writes about U.S. government

relations with multilateral organizations, including the World Health Organization and the World

Bank Group. Her major reports for CSIS include Catalyzing Health Gains through Global Polio

Eradication, which focused on polio transition in India; Bolstering Public Health Capacities through

Global Polio Eradication, which examined polio assets in Ethiopia; The Power of Straight Talk, which

looked at the impact of the Independent Monitoring Board on eradication efforts. Bristol came to

CSIS following a long career as a health policy journalist. She spent two decades writing about do-

mestic health policy on Capitol Hill before expanding her coverage to global health in 2005. Bristol

has written for top publications in the field including The Lancet, Health Affairs, and Congressional

Quarterly, covering HIV/AIDS policy, foreign aid and national security, noncommunicable diseases,

and efforts to combat maternal mortality. She holds a master’s degree in public health/global health

from George Washington University.

MICHAELA SIMONEAU is a program coordinator and research assistant for the CSIS Global Health

Policy Center, where she supports the polio, immunization, and nutrition portfolios. Prior to joining

CSIS, she worked as an intern on projects concerning antimicrobial stewardship, conflict resolution,

and human rights, and managed her university partnership with a grassroots non-profit organi-

zation in Coimbatore, India. Ms. Simoneau holds a B.S. in Biology and International Studies from

Boston College, where she wrote her senior thesis on the Rohingya refugee crisis.

SPECIAL THANKS TO:

Bjorn Melgaard, Independent Global Health Policy Consultant

Brent Burkholder, Independent Global Public Health Consultant

Ellyn Ogden, Worldwide Polio Eradication Coordinator, USAID

Amb. John E. Lange, Senior Fellow, Global Health Diplomacy, United Nations Foundation

Mara Pillinger, PhD Candidate, The George Washington University

Michael H. Merson, Wolfgang Joklik Professor of Global Health and Director, SingHealth

Duke-National University of Singapore Global Health Insurance

Michael McGovern, Chair, International PolioPlus Committee, Rotary International

This project is made possible through the generous support of the Bill & Melinda Gates Foundation.



Endnotes1) World Health Organization, Global Poliomyelitis Eradication by the Year 2000: Plan of

Action (Geneva: May 1980), p. 21

2) “Contributions and Pledges to the Global Polio Eradication Initiative, 1985-2019,” Glob-

al Polio Eradication Initiative, http://polioeradication.org/wp-content/uploads/2016/07/

GPEI-Historical-Contributions-Journals-Charts-v6.pdf.

3) India saw its last case of polio in January 2011 and was removed from the list of endemic

countries in 2014.

4) Thomas Abraham, Polio: The Odyssey of Eradication (London: Hurst Publishers, 2018), p. 133.

5) Global Polio Eradication Initiative, Independent Monitoring Board of the Global Polio Erad-

ication Initiative: Report (Geneva: October 2011), p. 18, http://polioeradication.org/wp-con-

tent/uploads/2016/07/IMBReportOctober2011.pdf.

6) Michael J. Toole, “So Close: Remaining Challenges to Eradicating Polio,” BMC Medicine 14,

no. 43 (2016), https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0594-6.

7) Abdul Qadir Sediqi and Stephanie Ulmer-Nebehay, “Afghan Taliban bans WHO and Red

Cross work amid vaccination drive,” Reuters, April 11, 2019, https://www.reuters.com/article/

us-afghanistan-taliban-aid/afghan-taliban-bans-who-and-red-cross-work-amid-vaccination-

drive-idUSKCN1RN257.

8) “Pakistan suspend polio vaccine drive after health worker attacks,” DW, April 27, 2019,

https://www.dw.com/en/pakistan-suspends-polio-vaccine-drive-after-health-worker-at-

tacks/a-48510718.

9) Global Polio Eradication Initiative, Review of Polio Endemic Countries (Geneva: September

2018), http://polioeradication.org/wp-content/uploads/2018/10/Review-of-Polio-Endem-

ic-Countries-2018.pdf.

10) Mara Pillinger, Re-fit for Purpose? The Ritual of Reform in Global Health Partnerships,

2019, (Doctoral dissertation).

11) “Contributions and Pledges to the Global Polio Eradication Initiative, 1985-2019,” Global

Polio Eradication Initiative.

12) “What We Do: Polio Strategic Overview,” Bill & Melinda Gates Foundation, https://www.

gatesfoundation.org/what-we-do/global-development/polio.

13) Global Polio Eradication Initiative, Independent Monitoring Board of the Global Polio

Eradication Initiative: Tenth Report (Geneva: October 2014), p. 8, http://polioeradication.org/

wp-content/uploads/2016/07/03E.pdf.


14) Transition Independent Monitoring Board of the Polio Programme, One Door Closes,

Another Opens (Geneva: Global Polio Eradication Initiative, December 2017), p. 7, http://

polioeradication.org/wp-content/uploads/2017/12/Second-TIMB-Report-December-2017-

171218-en.pdf.

15) Pillinger, Re-fit for Purpose?


About CSISEstablished in Washington, D.C., over 50 years ago, the Center for Strategic and International

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CSIS does not take specific policy positions; accordingly, all views expressed herein should be

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